| NPI | 1205888757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 658OD) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0601000803) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2011-04-28 |